Fill out this form below, and submit payment to complete your registrationRegister NowProfessionals Receiving CE Credits Live Only - $120 (Earn 5 CEs) On Demand Only - $140 (Earn up to 17 CEs) Live + On Demand - $160 (Earn up to 17 CEs) None General Registration Live Only - $80 (View 5 sessions) On Demand Only - $100 (View up to 17 sessions) Live + On Demand = $120 (View up to 17 sessions) None Student Registration Live Only - $55 (View 5 sessions) On Demand Only - $65 (View up to 17 sessions) Live + On Demand - $75 (View up to 17 sessions) None Name* First Last Contact Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Profession(For those earning CE Credits) LMFT LCSW LPCC LEP OT PSY SLP Professional License Number - Required for Professionals receiving CE credits Are you a parent? Yes No This Section is for Regional Center Parents OnlyThe California Regional Center’s will often cover the cost of the Summit for parents. Please speak with your regional center before registering. The Help Group Regional Center vendor number for the conference is PLO230. Ask your service coordinator for the conference promo code. If you have any questions about this process please call (818) 779-5210 or email events@thehelpgroup.orgAre you a Regional Center Parent that is being funded by your Regional Center? Yes Regional Center Name Child's Name First Last Service Coordinator Name First Last Service Coordinator Email Service Coordinator PhoneHow did you hear about the conference?* E-mail L.A. Times LA Parent Mailing Help Group Website Facebook Twitter Conference Posting Regional Center Summit Presenter Social Media Other Billing InformationTotal $0.00 Promo Code Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name
